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Development
Developmental Pediatrics is an essential part of pediatric practice that involves screening children's development through simple assessments using ordinary tools within a short time in a clinic setting. It is important to screen all children's development and give more thorough assessments to those with risk factors or suspected delays to enable early identification and management. Developmental screening can be done by observing a child's spontaneous activities and play to assess their motor, language, social, and fine motor skills development according to age-appropriate milestones.
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Development
- 1. Developmental Pediatrics DR.N.UDAYAKUMAR, ASSOCIATE PROFESSOROF PEDITRICS, SRMC&RI, PORUR. 1
- 2. Formal Screening Tests ASQ Clams Cat Earlyscreening inventory DenverII Denver I TDSC ELM Busy Pediatrician
- 3. “ I regarddevelopmental examination as an essential part of everyday practice with a minimum of equipment, in an ordinary mixed clinic, and not in a special room, or at a special time, or with special complicated equipment or by a special doctor ” R.S. Illingworth
- 4.
- 5. Develop. Screening All Children Develop.Assessment Quick Subjective Gen. Pediatrician in his clinic Children with perinatal events, risk factors, delay suspected Time consuming Objective - tests Dev. Pediatrician || Neurologist ENT Surgeon Ophthalmic Ortho Child psych. Physiotherapist occupational, speech School teacher Mother
- 6. Objectives • Sensitization -Dev. Screening • Early identification & appropriate referral • Simple format using – Ordinary tools – Within 10 - 15 minutes – Clinic / OP settings – Subjective assessment
- 7. Beyond the Scopeof this Lecture • Detail Assessment • Formal - objective tests Specific disabilities • ADHD, deafness, MR, autism, LD Special investigation • BERA
- 8. Why should weassess ? • To reassure parents • Early diagnosis and management of disability • Feedback for obstetrician and neonatologist • Prevention in next sibling
- 9. What to do? • Just passively observe his play and spontaneous activity • Use TDSC to screen • Go little more deeper with Development Chart (Lingam S. UK) • Need not memorise • Keeps the charts over the table and assess
- 10. Four Aspects ofDevelopment • Motor - Body posture & large movements • Fine movement, vision and manipulative skills • Hearing and speech • Social behaviour & spontaneous play Development Assessment is most conveniently divided into four fields Development Assessment is most conveniently divided into four fields
- 12. Developmental screening scale(S.Lingam 1987, UK) 4-6 weeks 3 months 6 months 9 months GROSS MOTOR Supine: head on sides, fencing, hands closed, thumbs in Pulled to sitting head momentarily erect and fall Held sitting: back curved Ventral suspension: Head in line with trunk Walking, stepping Supine: Head in midline Hands open, moves arm symmetrically Hands together in midline Pulls to sitting little or no headlag Kicks vigorously Ventral suspension-Head above trunk Prone lifts head with forearm support Supine: Raises head, lifts legs, grasp foot On grasping hand pulls self to sit Prone: Hand support Sitting with support straight back Downward parachute: Bears weight on feet Sits alone – 10-15 minutes Leans forward without losing balance Attempts to crawl Pulls to stand to crawl Forward parachute ( 7 m) Rolls over back to prone FINE MOTOR Turns eyes and head towards light Shuts eyes to bright light Regards mother face Follows ball ¼ circle Follows adult movements with available field Follows ball ½ circle Hand regard Finger play Defensive blink Moves head and eyes early in all directions Fixes eyes on objects Reaches and grasp Palmar grasp Transfers object from one had to other Very attentive Visual: Good peripheral vision Pokes at small objects Pincer grasp Watches rolling ball at 10 feet LANGUAGE ‘Startle’, stiffens Blinks, screws up eyes Fan out fingers Cries or freeze in response to noise Quietening or smilling to mother’s voice Turns immediately to mothers voice Mono and double syllable Responds to distraction hearing test at 1½ feet at ear level Laughs and chuckles Long repetitive string of syllable- Mama, Dada Understands no, no, bye bye Hearing test response 3 feet below and above SOCIAL Turns to regard nearby speaker’s face Stops crying when picked up and spoken to Social smile Fixes eyes on mother Unblinking, purposeful gaze Smiles, coos to familiar situations Reach and grasp small toys Takes to mouth Shakes rattle Holds bottle and feeds Still friendly with strangers Plays peek-A-Boo Holds, bites and chews biscuits Reserved with strangers (7m) Imitates hand clapping Finds a toy partly hidden WARNING SIGNS FOR FURTHER EVALUATION Not responding to nearby voices by 8 weeks Absent ‘Startle’ No social smile by 3 months Not showing interest in people/ playthings by 3-4 months No head control by 5 months No vocalization Persistent moro, asymmetric tonic neck reflex Not visually alert Not reaching for objects No hand transfer Not sitting No repetitive babble even by 10 months
- 13. Developmental Milestones AgeMilestones • 1 month Raises head slightly when prone; alerts to sound; regards face, moves extremities equally. • 2-3 months Smiles, holds head up, coos, reaches for familiar objects, recognizes parent. • 4-5 months Rolls front to back and back to front; sits well when propped; laughs, orients to voice; enjoys looking around; grasps rattle, bears some weight on legs. 14
- 14. • 6 monthsSits unsupported; passes cube hand to hand; babbles; uses raking grasp; feeds self crackers. • 8-9 months Crawls, cruises; pulls to stand; pincer grasp; plays pat-a-cake; feeds self with bottle; sits without support; explores environment. • 12 months Walking, talking a few words; understands "no"; says “mama/dada” discriminantly; throws objects; imitates actions, marks with crayon, drinks from a cup. 15
- 15. • 15-18 monthsComes when called; scribbles; walks backward; uses 4-20 words; builds tower of 2 blocks. • 24-30 months Removes shoes; follows 2 step command; jumps with both feet; holds pencil, knows first and last name; knows pronouns. Parallel play; points to body parts, runs, spoon feeds self, copies parents. 16
- 16. • 3 yearsDresses and undresses; walks up and down steps; draws a circle; uses 3-4 word sentences; takes turns; shares. Group play. • 4 years Hops, skips, catches ball; memorizes songs; plays cooperatively; knows colors; copies a circle; uses plurals. • 5 years Jumps over objects; prints first name; knows address and mother's name; follows game rules; draws three part man; hops on one foot. 17
- 17. Prevalence Low frequency highmorbidity – Cerebral palsy Visual or hearing impairment – Autism – Mental retardation High frequency low morbidity – Learning disability – ADHD
- 18. Clinical Presentation Early infancy –Poor suck, abnormal tone, lack of response to auditory or visual stimuli Late infancy – Motor delay II & III year – Language & behavioral abnormalities School entry – ADHD, learning disability
- 19. Three part assessment •History - Medical & Social • Examination - General & CNS • Developmental Screening
- 20. History • Risk factors –Prematurity – Adverse perinatal events – Family history • Warning signals – Mother’s suspicion – Inattention to sound • Dev. History – Tracking of Milestones
- 21. Physical examination • Growthparameters • Congenital anomalies • Skin findings • Eye findings • Abnormal facies • Organomegaly
- 22. Neurological examination • Classical •Extended examination – Symmetry – Quality of movement – Primitive reflexes – Postural response
- 23.
- 24. Dev. Screening -Tools of the Trade • One inch cubes • Hand bell • Pencil, paper • Small safe object • Safe interesting toy • Fluffy red wollen ball Plus (if possible) a smiling doctor
- 25. Order of testing •Develop. examination prior to P.E. • Language → social → fine → gross motor • Spend sometime in making friendship • Just observe him while he plays • Do quickly and efficiently
- 26. Ideal Environment forAssessment Place Mother’s lap Non threatening Time Not hungry, not sleepy Not sick, not fatigued Method By History Observation of play Formal examination
- 27. Primitive reflexes Persistence beyondthis, is abnormal • Palmar grasp (3 - 4 months) • MORO (5 months) • Asymm. Tonic reflex (6 months) • Plantar grasp (9 - 12 months)
- 28. Play - Events •Mouthing 6 months - 12 months • Bruxism - When awake usually suggest mental sub normality • Hand regard - 2 - 6 months • Casting (throwing) 1 - 11 /2 yrs • Handedness > 24 months • Tripod holding of pen > 21 /2 yrs • Drooling usually stops after one year
- 29. Testing of Hearing •Response to Noise – Startle, blinks, screws up eyes, cries or freeze in response to noise • Distraction testing (6 - 18 months) • Co-operative testing (18 - 30 months) • Performance test • Speech discrimination
- 30. Testing vision 1 month: Fixing on mother’s face 2 months : Follow objects at 90 cms Through 90o 3 months : Through 180o 10 months : Pick up raisin 1 year : Pickup 100s & 1000s 2 - 3 years : Miniature toys at 9 feet 3 - 5 years : Stycar matching letters > 5 years : Snellen chart
- 31. New born Ventralsuspension 6 weeks Head in same plane 18 weeks Head held up 12 weeks Floppy child12 weeks Floppy child
- 32. 4 weeks Completehead lag 2 months Partial head lag 4 months No head lag Lifting headup slightly
- 33. 6 weeks Chinoff couch intermittently 10 - 12 weeks Forearm support 24 weeks Hand support
- 34. 10 - 20weeks Hand regard
- 35. 44 weeks creepingposition 52 weeks Bear walk
- 36. 6 months Immature grasp 8months Intermediate grasp 1 year Mature grasp 10 months Index finger approach 10 months Pincer grasp
- 37. 3 weeks Palmar graspreflex
- 38.
- 39.
- 40. 6 weeks Concentrating onrattle Beginning of eye - hand coordination
- 41.
- 42. 4 months Head control,eye contact, good interaction
- 43. 4 months Holding head& looking further away
- 44. 5 months Palmar graspand biting the rattle
- 45. 5 months Reaching outfor rattle
- 46. 6 months Bearing weighton legs
- 47. 6 months Holding andexploring rattle
- 48. 6 months Turning tosound of rattle
- 49. 6 months Sitting withsupport examining the mat
- 50.
- 51. 10 months Finding hiddenobjects
- 52. 1 year Examining thesoap box with interest (house hold objects can be used)
- 53. 1 year Communicating withgestures Mother holding out hand - baby gives the toy Communicating with gestures Mother holding out hand - baby gives the toy
- 54. 1 year Walking withbroad base in response to mother’s call Walking with broad base in response to mother’s call
- 55. 1 year Making gesturesto communicate pointing with leaf
- 56. 1 year Imitating andcopying Both are striking the wooden blocks Imitating and copying Both are striking the wooden blocks
- 57. 2 years 2 1 /2years 3 years 4 years 4 1 /2 years 5 1 /2 years 6 1 /2 years Drawing tests - L O C S T D
- 58. Interpretation • Give allowancefor prematurity, fatigue, illness, familial pattern • If in doubt, repeat later • Remember - wide range of normal deviation
- 59. After the DevelopmentalExamination • Is there any delay ? • Can it be a normal variant ? • Is it global delay or dissociation between fields ? • If not definite, can I decide after repeating the test ? • Can I ask for help ?
- 60. • Language perceptionis well advanced than expression • Some do bear walk • Some bounce around floor (Bottom shuffling) • Some do side stroke, crawl backwards or roll • Some never crawl; they stand and walk Normal Variant
- 61. Causes of MotorDelay • Normal or Familial variation bottom shuffling • Chronic illness • CP • Neuromuscular diseases - DMD, SMA • Orthopedic - CDH • Rickets • Emotional neglect
- 62. Warning Signals inLanguage Development • Risk of deafness • Mother’s suspicion • No response to everyday sounds • No repetitive babble by 10 months • No word by 21 months • Not putting 2 - 3 words together by 21 /2 years
- 63. Language delay • Receptionis well advanced than expression – Hearing defects – Familial & genetic – Global delay – Autism – Environmental
- 64. Global Delay • Chromosomaldefects • Syndromes • CP • Structural brain defects • Neurometabolic problems • Postnatal causes
- 65. Factors affecting development •Genetic • Physical • Nutritional • Emotoinal • Sociocultural • Neurological 66
- 66. Developmental Quotient • Computedby the following formula • Developmental age / Chronological age X 100 67
- 67. INTELLECTUAL QUOTIENT • MENTALAGE /CHRONOLOGICAL AGE. • <70- MENTAL RETARDATION. • GLOBAL DEVELOPMENTAL DELAY <3 YEARS. 68
- 68. Development assessment scales •Denver Development Chart • Baroda Developmental Screening chart • Trivandrum Developmental Screening chart • Bayley Scale of Infant Development (BSIS) • Developmental Assessment Scale for Indian Infants(DASII) 69
- 69. BONE AGE • ATBIRTH UPTO 4 MONTHS- KNEES AND HIP. • 4-12 MONTHS-SHOULDER. • 1 -10 YEARS- WRIST. • > 8- 14 YEARS-ELBOW. • ( LEFT SIDE BONES ARE ASSESSED) 77
- 70. WHO GROWTH CHART •In an effort to set an internationally usable standard for optimal growth in young children, the World Health Organization is conducting the Multicenter Growth Reference Study (MGRS) to develop growth curves that can be used for assessing early growth among children from around the world. • MGRS describes the growth of children who are raised under optimal conditions, following recommended health practices, such as environments that support exclusive breast-feeding, Baby- Friendly Hospitals, and mothers who agree to breast-feed their infants. • Six study sites represent 5 continents in the major regions of the world: United States, Brazil, Norway, Ghana, Oman, and India. 78
- 71. SLEEP EVALUATION • TheBEARS instrument is divided into 5 major sleep domains, providing a comprehensive screen for the major sleep disorders affecting children 2–18 years old. Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview. 79
- 72. To conclude …... Screenthe development in all well children • Observe his play and spontaneous activity • Use TDSC to screen • Go little more deeper with Development Chart (Lingam S. UK) - if there is suspicion • Keeps the charts over the table
- 73. Decisions • Abnormal • Probablynormal • Doubtful • Normal See again Refer
- 74. Developmental assessment by MKC Nair Manual ofchild development by Lingam S First 5 years by Mary Sheriden PCNA - Child with developmental disabilities - June 1993 For further reading
Editor's Notes
- #3 Dev assessment / screening is only a part of child health surveillance.
- #7 Dev screening is aimed at presymptomatic detection of disability by examining children serially to determine whether they are developmentally normally developed? Screening process should be brief, simple, cheap and reliable. Appropriate timing is 6 weeks, 8 mo, 18 mo, 2 ½ yrs and 4-5 yrs. Screening may be combined with immunization or routine visits. Done by a doctor, health worker or a trained person. Dev assessment is carried out on a child discovered by dev screening to have dev dela or behavioural disorder to establish wheher there is a problem and if so the type and causes. This carried out by a team lead by a developmental pediatrician
- #36 Child playing with foot and hands and keep foot in the mouth. Starts at about 4 mo and should disappears by 9 mo. Persistence beyond 1 yr indicates dev delay